Freestanding ER Study Author: Findings Distorted in Media

Worries about 'false undervaluing of emergency care and emergency physicians'

The results of study that compares costs to consumers at freestanding emergency departments and urgent care centers for seemingly comparable medical services have been skewed by the news media and partisans in the debate, says a co-author of the study.

Referring to the study published in Annals of Emergency Medicine, Cedric Dark, MD, said, "I stand behind the science of the study 100%." Dark is an assistant professor of emergency medicine at Baylor College of Medicine.

"Unfortunately, many in the press and in the political world, seem to want to extrapolate our findings inappropriately and thus contribute to the false undervaluing of emergency care and emergency physicians," he said.

Dark said conclusions about the study reflect how readers choose to interpret the data.

"Some people will interpret it with an economic slant. Some people will interpret it with a patient-provider perspective. I like to make the comparison mostly to the freestanding emergency department versus hospital-based emergency department and demonstrate that those costs are roughly equivalent," he said.

Dark, who practices in both FEDs and HBEDs, said there is little value in comparing the costs of care delivered at FEDs and urgent care centers because they are entirely different care venues that don't provide the same level of care.

"Urgent care centers are less expensive, but do not offer the same services as either emergency department setting. Our study compares apples (FSEDs and HBEDs) to oranges (UCCs)," Dark said in a letter to HealthLeaders.

"It's no surprise to me that UCCs are so much less expensive -- they don't staff with board-certified emergency medicine doctors, they don't have to stay open 24/7/365 and they don't have CT scanners or other equipment and operating costs of an emergency department."

"UCCs are also not required to provide millions of dollars in uncompensated care like FSEDs and HBEDs," he said. "UCCs cannot diagnose things like appendicitis or gallstones or intestinal obstructions. UCCs typically don't even have the equipment to do so."

Costs 'Roughly Equivalent'

Dark said that while UCCs offer less-expensive alternatives for clearly non-emergency care, the problem is that patients often can't tell the difference.

"What people should understand from our study is that FSEDs and HBEDs are roughly equivalent in cost. Only the physician utilizing all the tools at his or her disposal can determine if an emergency medical condition exists," he said.

Dark said the study only looked at final diagnosis and did not provide much detail on the patient encounters at any of the care venues.

"We were unable to adjust for age, medical complexity, or acuity level because we were only looking at the final diagnosis," he said. "Let's compare, for example, a healthy 20-year-old male who goes to an UCC for abdominal pain. If he has no medical problems and has a normal physical exam, the clinician would not likely need labs or a CT scan or any other testing."

By comparison, Dark offered a 60-year-old woman with colon cancer who complains of abdominal pain.

"Because of her age, risk factors, and previous medical problems, it would be necessary to order labs, a urine test, a CT scan and possibly other testing to rule out a life threatening emergency," he said. "At the end of the day, her work-up might be negative, but the physician would have ruled out a life-threatening cause. She would be discharged with the same diagnosis of 'abdominal pain.' While the final diagnosis might be the same, her bill is much more expensive because of increased complexity, higher acuity, and resources needed to care for her."

The data was also limited to outpatient visits. "Thus, more serious conditions such as heart attacks, strokes, or anything requiring surgery could not be addressed. Urgent care centers are neither equipped to diagnose nor treat these life-threatening conditions," Dark said.

In addition, he said, looking at final outcomes does not take into account the patient's state of mind when they're accessing care.

"Looking with hindsight at final diagnoses, while a commonly accepted method for research, is not a fair way to judge what a prudent layperson believes is an emergency when they walk in the door. Patients don't show up with a pre-specified diagnosis, but instead symptoms that may vary dramatically in severity," he said.

Dark said he fears the study could be used to "threaten the 24/7/365 access to emergency care all Americans currently enjoy."

"But I do believe that to keep it all affordable, price transparency and patient education are essential," he said. "Insurance plans should cover emergency care as an essential benefit and must be able to tell consumers what the anticipated costs will be."

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